US20210262005A1 - Method for detecting synovial joint infections - Google Patents

Method for detecting synovial joint infections Download PDF

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US20210262005A1
US20210262005A1 US17/251,492 US201917251492A US2021262005A1 US 20210262005 A1 US20210262005 A1 US 20210262005A1 US 201917251492 A US201917251492 A US 201917251492A US 2021262005 A1 US2021262005 A1 US 2021262005A1
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synovial
substrate
synovial joint
lysozyme
infection
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Andrea HEINZLE
Clemens GAMERITH
Daniel Luschnig
Eva Sigl
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Qualizyme Diagnostics GmbH and Co KG
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    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
    • C12Q1/00—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions
    • C12Q1/34—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions involving hydrolase
    • C—CHEMISTRY; METALLURGY
    • C12—BIOCHEMISTRY; BEER; SPIRITS; WINE; VINEGAR; MICROBIOLOGY; ENZYMOLOGY; MUTATION OR GENETIC ENGINEERING
    • C12Q—MEASURING OR TESTING PROCESSES INVOLVING ENZYMES, NUCLEIC ACIDS OR MICROORGANISMS; COMPOSITIONS OR TEST PAPERS THEREFOR; PROCESSES OF PREPARING SUCH COMPOSITIONS; CONDITION-RESPONSIVE CONTROL IN MICROBIOLOGICAL OR ENZYMOLOGICAL PROCESSES
    • C12Q1/00—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions
    • C12Q1/26—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions involving oxidoreductase
    • C12Q1/28—Measuring or testing processes involving enzymes, nucleic acids or microorganisms; Compositions therefor; Processes of preparing such compositions involving oxidoreductase involving peroxidase
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N2333/00—Assays involving biological materials from specific organisms or of a specific nature
    • G01N2333/90—Enzymes; Proenzymes
    • G01N2333/914—Hydrolases (3)
    • G01N2333/924—Hydrolases (3) acting on glycosyl compounds (3.2)
    • G01N2333/936—Hydrolases (3) acting on glycosyl compounds (3.2) acting on beta-1, 4 bonds between N-acetylmuramic acid and 2-acetyl-amino 2-deoxy-D-glucose, e.g. lysozyme
    • G—PHYSICS
    • G01—MEASURING; TESTING
    • G01N—INVESTIGATING OR ANALYSING MATERIALS BY DETERMINING THEIR CHEMICAL OR PHYSICAL PROPERTIES
    • G01N2800/00—Detection or diagnosis of diseases
    • G01N2800/10—Musculoskeletal or connective tissue disorders

Definitions

  • the present invention relates to methods for detecting infections in synovial joints.
  • the infection of joints such as knees, hips or shoulders is usually the result of a surgical procedure or injuries in which bacteria or viruses can enter the joints.
  • artificial joints or implants are often affected by such infections.
  • the detection of a bacterial infection, for instance, in joints is carried out by means of a joint puncture with synovial analysis, whereby the bacteria are detected by culturing on special culture media in an incubator.
  • a negative culture result does not prove that it is free of any germs, as there are up to 30% false negative tests (Simank HG et al. (2004) Joint Anemia Orthopedist 33: 327-31).
  • This microbial cultivation detection system usually takes 2 to 5 days.
  • a leukocyte count can be performed in the synovial fluid (leukocyte/mm 3 ).
  • Septic arthritis also known as infectious or—if bacteria are involved—bacterial arthritis is a dangerous disease. Depending on the germ, it can lead to considerable damage in the joint within a very short time. This is especially true for infection with Staphylococcus aureus . In addition, it can lead to a seeding of the pathogens into the bloodstream and, as a consequence, to a life-threatening general infection (sepsis).
  • the present invention relates to a method for detecting a synovial joint infection comprising the steps of
  • a synovial joint infection can be detected by determining lysozyme activity in the synovial fluid of a mammal suffering from a synovial joint condition, wherein the enzymatic activity is preferably determined in an untreated synovial fluid sample obtained directly from said mammal (i.e. obtained by puncturing a synovial joint of a mammal).
  • an untreated synovial fluid sample obtained directly from said mammal (i.e. obtained by puncturing a synovial joint of a mammal).
  • the findings of the present invention allow to differentiate synovial joint conditions into synovial joint infection and a non-infectious inflammatory condition within minutes.
  • Another aspect of the present invention relates to a method for discriminating between a synovial joint infection and a non-infectious inflammatory condition of a synovial joint comprising the steps of
  • the present invention describes an in vitro system for detecting infections, in particular bacterial infections, in mammalian synovial fluids. Infections can be identified by the method of the present invention within minutes since the lysozyme activity in infectious joints is significantly higher compared to healthy mammals and mammals suffering from non-infectious inflammatory condition.
  • substrates are used for the conversion with lysozyme which are able to release a marker which may be detected optically using, for instance, photometric methods or test stripes.
  • lysozyme which are able to release a marker which may be detected optically using, for instance, photometric methods or test stripes.
  • the present invention enables a rapid result in terms of a possible infection directly in the ambulance or in the case of horses and cattle in the barn.
  • the result is immediate, no lab or time-consuming microbiology is needed for the first diagnosis.
  • Enzymes in synovial fluids which are secreted by the body's immune system in case of bacterial joint infections to an increased extent, are detected preferably by a simple and rapid color reaction system.
  • the targeted preparation of the sample material enables the sample to be quickly and reliably transferred to the new test system.
  • Experimental data clearly show that in the case of a synovial infection different enzymes are significantly increased and a distinction between bacterial and inflammatory events is possible.
  • FIG. 1 shows the Box-Plot of Lysozyme concentrations in no synovial joint condition (NSJC), aseptic arthritic (ASA) and septic (S) synovia samples.
  • NSJC no synovial joint condition
  • ASA aseptic arthritic
  • S septic
  • FIG. 2 shows the Box-Plot of MPO concentrations in no synovial joint condition (NSJC), aseptic arthritic (ASA) and septic (S) synovia samples.
  • NSJC no synovial joint condition
  • ASA aseptic arthritic
  • S septic
  • FIG. 3 shows the absorbance values measured in the lysozyme activity assays according to example 2.
  • FIG. 4 shows the time-depending dye release from peptidoglycan-reactive black 5 using increasing concentrations of lysozyme.
  • FIG. 5 shows the influence of the substrate concentration on the reaction kinetics of lysozyme.
  • the present invention relates to a method for detecting a synovial joint infection.
  • synovial fluid obtained from healthy joints as well as from joints from mammals suffering a non-infectious inflammatory condition of a synovial fluid (e.g. arthritis, in particular rheumatoid arthritis).
  • a non-infectious inflammatory condition of a synovial fluid e.g. arthritis, in particular rheumatoid arthritis.
  • lysozyme activity can be detected in serum and synovial fluid samples from patients suffering from rheumatoid arthritis using a test system which is based on the lysis of the cell wall of Micrococcus lysodeiktikus (as agar diffusion test).
  • a test system which is based on the lysis of the cell wall of Micrococcus lysodeiktikus (as agar diffusion test).
  • the examples provided herein clearly show that lysozyme activity in healthy patients is not detectable or only to a very low degree. It has to be noted that Pruzanski W et al. (1970) did not determine lysozyme activity in synovial fluid of healthy individuals so that the lysozyme activity disclosed therein cannot be an indicator for determining whether an individual suffers from rheumatoid arthritis.
  • Synovial joint refers to plane joints (or gliding joint), hinge joints, pivot joints, condyloid joints (or ellipsoidal joints), saddle joints and ball and socket joints. All of these joints are filled with synovial fluid, which is required to reduce friction between the articular cartilage of synovial joints during movement.
  • “Synovial joint infection”, as used herein, refers to infections caused by bacteria, fungi and/or viruses. These infections may be the result of a mechanical injury causing the infiltration of bacteria, fungi and/or viruses into a synovial joint. However, joint infections may also occur in the course or after surgery. A further source of infection can be blood if the blood of the mammal contains respective microorganisms and/or viruses.
  • synovial joint infections are Staphylococcus aureus, Staphylococcus epidermidis , hemolysing streptococci of group A, pneumococci, Pseudomonas aeruginosa, Proteus mirabilis, E. coli, Haemophilus influenzae , propionibacteria and salmonellae.
  • other aerobic and anaerobic germs as well as fungi like Candida albicans may be responsible for synovial joint infections (e.g. Hepburn M J, et al. Rheumatol Int. (2003) 23:255-7; Lequerre T, et al. (2002) Joint Bone Spine 69(5):499-501)
  • substrate in particular “lysozyme substrate”, as used herein, includes compounds, which can be converted (e.g. hydrolysed, degraded) by enzymes like lysozyme or which interact in another specific way with enzymes.
  • the synovial fluid sample is of a mammal showing symptoms of a synovial joint condition.
  • synovial joint infections in mammals suspected to suffer from a synovial joint condition, since obtaining synovial fluid is invasive and requires punctuation of the joint.
  • another aspect of the present invention relates to a method for discriminating between a synovial joint infection and a non-infectious inflammatory condition of a synovial joint comprising the steps of
  • Substantially no lysozyme activity and “no lysozyme activity”, as used herein refers to a lysozyme activity which is not detectable by the method described herein, in particular in example 1, however preferably of less than 200 U/ml.
  • Lysozyme activity can be determined by using various methods known in the art. Preferred methods involve the conversion of a specific substrate into a product which can thereafter been detected and quantified. Such methods may involve also substrates which are able to release detectable substances like dyes. A particularly preferred method to determine lysozyme activity is described, for instance, in EP 2 433 138.
  • the lysozyme substrate used in the methods described therein is preferably a peptidoglycan and/or chitosan, or oligomers of these, more preferably a peptidoglycan and/or chitosan dyed with a vinyl sulfone dye.
  • the peptidoglycan may be derived from Micrococcus lysodeictikus.
  • the substrate concentration of stained peptidoglycan can be within a range of 1 mg/ml to 50 mg/ml, preferably 10 mg/ml-20 mg/ml, in particular 15 mg/ml.
  • the lysozyme substrate is incubated with the synovial fluid sample for a defined time or time range. It is particularly preferred to incubate the synovial fluid sample with the lysozyme substrate for 1 to 30 min, preferably 1 to 20 min, more preferably for 1 to 15 min, more preferably for 1 to 10 min, more preferably for 2 to 30 min, more preferably 2 to 20 min, more preferably for 2 to 15 min, more preferably for 2 to 10 min, more preferably for 5 to 30 min, more preferably 5 to 20 min, more preferably for 5 to 15 min, more preferably for 5 to 10 min.
  • the method of the present invention has the advantage that the synovial fluid used therein can be used without any preparation step.
  • synovial fluid obtained from the joint of a mammal can be directly used to assess its lysozyme activity. This is surprising since the methods known in the art do not use synovial fluid directly to determine lysozyme activity. For instance, Pruzanski W et al. (1970) suggest to centrifuge the synovial fluid to be analysed and to dialyze it before contacting it with the lysozyme substrate.
  • the non-infectious inflammatory condition of a synovial joint is inflammatory arthritis, preferably rheumatoid arthritis, acute aseptic arthritis or osteoarthritis, osteochondrosis and inflammation caused by traumatic events.
  • the synovial joint infection is a bacterial, fungal or viral infection
  • bacterial infections may be preferably caused by Staphylococcus aureus, Staphylococcus epidermidis , hemolysing streptococci of group A, pneumococci, Pseudomonas aeruginosa, Proteus mirabilis, E. coli, Haemophilus influenzae , propionibacteria and salmonellae, and fungal infections may preferably caused by Candida albicans.
  • Synovial joint infections may be caused by one or more of the organisms listed above. Infections caused by one or more of these organisms can be treated with medicaments like antibiotics as well-known in the art.
  • the method of the present invention is preferably used with samples obtained from mammals which show symptoms of a synovial joint condition.
  • the symptoms of a synovial joint condition include preferably pain, joint swelling, fever and/or inability to move the limb with the infected joint.
  • the synovial joint infection is detected when the lysozyme activity within the sample is at least 500 U/ml, preferably at least 600 U/ml, more preferably at least 700 U/ml, more preferably at least 800 U/ml, more preferably at least 900 U/ml, more preferably at least 1,000 U/ml.
  • synovial fluid is derived from a joint having an infection caused by one of the pathogens/organisms mentioned above.
  • a non-infectious inflammatory condition is detected when the lysozyme activity within the sample is less than 500 U/ml, preferably less than 400 U/ml, more preferably less than 300 U/ml, more preferably less than 200 U/ml.
  • the at least one lysozyme substrate is peptidoglycan or a derivative thereof.
  • Lysozyme is known to destroy bacterial cell walls by hydrolysing 1,4-beta-linkages between N-acetylmuramic acid and N-acetyl-D-glucosamine residues in peptidoglycan. In addition to its lytic activity against Gram positive bacteria, lysozyme can act as a non-specific innate opsonin by binding to the bacterial surface, reducing the negative charge and facilitating phagocytosis of the bacterium before opsonins from the acquired immune system arrive.
  • the lysozyme substrate may have a structure A-I (Formula I) wherein, A is an anchor and I is an indicator region, wherein the indicator (I) or a motif therein is conjugated to the anchor and the conjugate is a substrate for lysozyme (see WO 2017/168249).
  • the anchor region (A) is associated with the indicator region (I) via an enzyme recognition site (S).
  • the enzyme recognition site is a structure or a motif that allows binding to an enzyme.
  • the enzyme recognition site (S) is naturally present in the anchor region. In another embodiment, the enzyme recognition site (S) is introduced in the anchor region via chemical modification. Alternately, the enzyme recognition site (S) may be naturally present in the indicator region (I) or synthetically introduced in the indicator region (I) via one or more chemical modifications.
  • the chemical entity of Formula I comprises an anchor (A) which is associated with the indicator (I), either covalently or non-covalently.
  • the association between the anchor region (A) and the indicator region (I) is mediated via a covalent interaction.
  • covalent bonds involve sharing of electrons between the bonded atoms.
  • non-covalent bonds may include, for example, ionic interactions, electrostatic interactions, hydrogen bonding interactions, physiochemical interactions, van der Waal forces, Lewis-acid/Lewis-base interactions, or combinations thereof.
  • the anchor A is associated with the indicator I via a covalent interaction to form the recognition site S. In another embodiment, the anchor A is associated with the indicator I via a covalent interaction that is not a part of the recognition site S.
  • the chemical entity further comprises an enzyme-labile or enzyme-reactive region (R).
  • the reactive region (R) is a part of the anchor region.
  • the reactive region (R) is a part of the indicator region (I).
  • the reactive region (R) is a part of the enzyme recognition site (S).
  • the reactive region (R) interacts with lysozyme or myeloperoxidase, or a combination thereof.
  • the backbone of the lysozyme substrate can be chitosan, peptidoglycan or any derivative thereof, whereas peptidoglycan is preferred.
  • the reactive dyes for staining the substrate may have different amounts of sulfonate groups ranging from 1-6 sulfonate groups.
  • the backbone can be stained with Reactive Red 120 or reactive green 19 (6 sulfonate groups); with Reactive Blue 109 (5 sulfonate groups); with Reactive Brown 10 (4 sulfonate groups).; with Reactive blue 5 (3 sulfonate group); with Reactive Black 5 or reactive violet 5 (2 sulfonate groups); with Reactive Orange 16 or Reactive blue 19 (1 sulfonate group).
  • the synovial fluid sample is further contacted with at least one myeloperoxidase substrate and a synovial joint infection is detected when a conversion of said at least one substrate is determined.
  • MPO activity is known to be significantly increased in infectious tissue.
  • the additional determination/quantification of MPO activity in a synovial fluid sample may be used to confirm that the synovial joint is infected.
  • the synovial joint infection is detected when the myeloperoxidase activity within the sample is at least 0.1 U/ml, preferably at least 0.2 U/ml, more preferably at least 0.3 U/ml, more preferably 0.4 U/ml, more preferably at least 0.5 U/ml, more preferably at least 1 U/ml.
  • the at least one myeloperoxidase substrate is selected from the group consisting of Guajacol, 3,4-Diamino benzoic acid, 4-Amino-3-hydroxy benzoic acid, Methyl-3,4-diaminibenzoate, 3-Amino-4-hydroxy benzoic acid, 2,3-Diamino benzoic acid, 3,4-Dihydroxy benzoic acid, 2-Amino phenol, 2-Amino-3-methoxy benzoic acid, 2-Amino-4-methylphenol, 3,3′,5,5′-tetramethylbenzidin, 2,2′-azino-bis(3-ethylbenzthiazoline-6-sulphonic acid), crystal violet, leuko crystal violet and sinaptic acid Fast Blue RR modified with isocyanate.
  • MPO activity can be determined using the following detection system for the detection of elevated MPO levels in synovial fluid.
  • the system comprises of a reaction vessel filled with a defined volume of a phosphate buffer (100-1400 ⁇ l, sodium or potassium, pH 6.2-8.0, 10.0-100 mM).
  • the synovial fluid sample (100-1400 ⁇ l) is then transferred into the reaction vessel containing the pre added buffer. Therefore, the dilution factor can range from 10:1 to 1:10. The most preferred dilution factor ranges from 2:1-1:2.
  • the MPO substrate is added in solid form, for instance as tablet, and can contain one of the aforementioned substrates and most preferred a substrate selected from the group consisting of Guajacol, 3,4-Diamino benzoic acid, 4-Amino-3-hydroxy benzoic acid, Methyl-3,4-diaminibenzoate, 3-Amino-4-hydroxy benzoic acid, 2,3-Diamino benzoic acid, 3,4-Dihydroxy benzoic acid, 2-Amino phenol, 2-Amino-3-methoxy benzoic acid and 2-Amino-4-methylphenol.
  • a substrate selected from the group consisting of Guajacol, 3,4-Diamino benzoic acid, 4-Amino-3-hydroxy benzoic acid, Methyl-3,4-diaminibenzoate, 3-Amino-4-hydroxy benzoic acid, 2,3-Diamino benzoic acid, 3,4-Dihydroxy benzoic acid, 2-Amino phenol, 2-Amino-3-methoxy be
  • the tablet may have a weight of 10-100 mg where the optimum is 20 mg.
  • the tablets may be pressed with a pressure of 2 t for 10 seconds with a diameter of 5 mm.
  • the whole system After the addition of the substrate to the synovial fluid sample, the whole system is well mixed and the enzymatic reaction starts immediately. Depending on the level of MPO activity a visible colour change of the solution can be observed. The arising colour is depending on the active ingredient and can be yellow, orange, red, brown, black or any combination thereof.
  • the mammal is selected from the group consisting of human, cattle, pigs, sheep and horses.
  • Example 1 Determination of Lysozyme Activity in Synovial Fluid Samples Obtained From Healthy Patients and Patients Suffering From Rheumatoid Arthritis and Microbial Infections of a Synovial Joint
  • Lysozyme is an enzyme, which is produced and secreted by cells of the innate immune system.
  • Peptidoglycan is the main building block of cell walls from gram positive bacteria and can be cleaved by lysozyme. This is a natural defence mechanism from the immune system to cope with bacteria by digesting their cell walls. It was demonstrated, that in 100% (see Table 1, Sensitivity) of the tested synovia samples which were diagnosed as septic by the responsible clinicians, the lysozyme activity was elevated. Moreover, 100% (see Table 1, Specificity) of the samples which were classified as negative or inflammatory did not show elevate lysozyme levels.
  • 7.5 mg peptidoglycan-reactive black 5 were suspended in 0.990 ml 0.9% NaCl solution. 10 ⁇ l of different lysozyme concentrations were added to the reaction solution to final concentrations ranging from 0 U/ml-10000 U/ml (every concentration in triplicates). All samples were incubated at 37° C. for 60 minutes and shaking at 1400 rpm. After the incubation step all samples were centrifuged at 10000 g for 5 minutes. 100 ⁇ l of each supernatant were transferred into a 96 well plate and absorbances were measured at 597 nm. Absorbance values are shown in FIG. 3 . All lysozyme concentrations could be clearly distinguished.
  • peptidoglycan-reactive black 5 7.5 mg/ml peptidoglycan-reactive black 5 were suspended in 0.990 ml 0.9% NaCl solution. 10 ⁇ l of a lysozyme solution were added to a final concentration of 10000 U/ml. All samples were incubated at 37° C. for 10-60 minutes and 1400 rpm. Every 10 minutes triplicates were centrifuged (10000 g, 5 min) and 100 ⁇ l of the supernatants were transferred into a 96 well plate. The absorbance was measured at 597 nm. The time-depending dye release is shown in FIG. 4 . Already after 10 minutes the
  • Example 5 Determination of MPO Activity in Synovial Fluid Samples Obtained From Healthy Patients and Patients Suffering From Rheumatoid Arthritis and Microbial Infections of a Synovial Joint
  • MPO is also an enzyme from the innate immune system and acts as a natural defence mechanism against bacteria by producing highly active oxygen species.
  • One possible MPO reaction is the oxidation of substrates using H 2 O 2 as cofactor.
  • the second mechanism known is the chlorination activity which can also lead to the oxidation and/or cleavage of molecules.
  • chromogenic substrates are known to change colour upon oxidation reactions and can therefore be used for the detection of MPO activity.
  • a guajacol based assays was used for the determination of MPO activity and was carried out as follows:
  • Example 6 Determination of Elastase Activity in Synovial Fluid Samples Obtained From Healthy Patients and Patients Suffering From Rheumatoid Arthritis and Microbial Infections of a Synovial Joint
  • the enzyme elastase is also described as a marker enzyme in synovia.
  • Elastase is a proteolytic enzyme and cleaves proteins with specific recognition sequence. This can be used to cleave of chromophores from substrate proteins. The following assay was used for the determination of the elastase activity.
  • Methoxysuccinyl-Ala-Ala-Pro-Val-p-nitroanilid was used as substrate. By cleaving the p-Nitroaniline from the peptide, a yellow colour is emerging and can be measured at 405 nm.
  • the substrate was dissolved in Dimethyl sulfoxide and dilute with a sodium phosphate buffer (10-50 mM, pH 6.0-8.0). The final substrate concentration was 1-5 mM.
  • Example 7 Determination of Cathepsin Activity in Synovial Fluid Samples Obtained From Healthy Subjects and Subjects Suffering From Rheumatoid Arthritis and Microbial Infections of a Synovial Joint
  • synovial fluid 10 ⁇ l synovial fluid (equine) of healthy horses, subjects suffering from rheumatoid arthritis and microbial infections were added each to 90 ⁇ l of a 3 mM solution of Cathepsin G substrate (N-Succinyl-Ala-Ala-Pro-Phe p-ni-troanilide) (stock solved 30 mM in DMSO) in sodium phosphate buffer (25 mM, pH 7.0, 0.5 M NaCl). Absorbances were measured at 405 nm for 20 minutes at 37° C. 9 samples were analysed: 3 septic and 3 aseptic (arthritis) synovia samples as well as 3 synovial fluid samples from healthy subjects. Cathepsin G activity could not be measured in any sample.
  • Cathepsin G substrate N-Succinyl-Ala-Ala-Pro-Phe p-ni-troanilide
  • sodium phosphate buffer 25 mM, pH 7.0

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EP18182042.4 2018-07-05
EP18182042.4A EP3591066A1 (fr) 2018-07-05 2018-07-05 Procédé de detection d'infections synoviales articulaires
PCT/EP2019/068112 WO2020008039A1 (fr) 2018-07-05 2019-07-05 Méthode de détection d'infections de l'articulation diarthrodiale

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JP2019513238A (ja) 2016-03-30 2019-05-23 クオリザイム・ダイアグノスティクス・ゲゼルシャフト・ミット・ベシュレンクテル・ハフツング・ウント・コムパニー・コマンディットゲゼルシャフトＱｕａｌｉｚｙｍｅ Ｄｉａｇｎｏｓｔｉｃｓ Ｇｍｂｈ Ａｎｄ Ｃｏ． Ｋｇ 創傷における微生物感染の検出

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Title
Bennett et al. "Lactoferrin and Lysozyme levels in synovial fluid", Arthritis and Rheumatism, 1977, Vol. 20, No.1, pp.84-90. (Year: 1977) *
Hadler et al. "Lysosomal enzymes in inflammatory synovial effusions", The Journal of Immunology, 1979, Vol. 123, No. 2, pp.572-577. (Year: 1979) *
Okamoto et al. "Determination of lysozyme activity by fluorescence polarization in rheumatoid synovial fluids and release of lysozyme from polymorphonuclear leukocytes by chemotactic factors", Journal of Immunological Methods, 1987, Vol. 103, pp. 221-227. (Year: 1987) *

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AU2019297554A1 (en) 2021-01-07
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BR112020026923B1 (pt) 2022-11-16
MX2020013326A (es) 2021-03-09
WO2020008039A1 (fr) 2020-01-09
EP3591066A1 (fr) 2020-01-08
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BR112020026923A2 (pt) 2021-03-30
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